Transcribed Medical Transcription Sample Reports and Examples
MT HelpLine Transcribed Medical Transcription Sample Reports and Examples
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as on 3/19/2014
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Sample Type / Medical Specialty: General Medicine

A branch of medicine that deals with diagnosis and treatment of nonsurgical diseases.



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Medical Management Consult Request
Patient with Hypertension, atrial fibrillation, large cardioembolic stroke initially to the right brain requesting medical management

Melena - ICU Followup
Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.

Motor Vehicle Accident
Multiple contusions and abdominal pain, status post motor vehicle collision.

MRI Brain - CO poisoning
MRI Brain, Carbon Monoxide poisoning.

Multiple Medical Problems - Discharge Summary
Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, and congestive heart failure.

Nausea - ER Visit
Nausea and feeling faint. She complains of some nausea. She feels weak. The patient is advised to put salt on her food for the next week.

Nausea & Vomiting - ER Visit
She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.

Normal Child Exam Template
Normal child physical exam template.

Normal ENT Exam
Sample normal ear, nose, mouth, and throat exam.

Normal ENT Exam - 1
Sample normal ear, nose, mouth, and throat exam.

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NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples